The Recalcitrant Physician  You are an ICU clinical leader in a tertiary hospital that is implementing the ABCDE bundle. The hospital critical care committee has approved modifications to the Adult Ventilator Order Set such that bundle interventions are now a pre-checked, “opt out” order. As you monitor bundle adoption (which is hovering consistently at 50-60% after 9 months), the feedback you consistently hear from nursing is that physicians are not using the Adult Ventilator Order Set (preferring instead to write daily line-item orders after they have personally examined the patient-even if that occurs in the late afternoon), and they do not seem to be responding to notifications of a “CAM-ICU Positive” score.  How do you engage the ICU physician staff to gain buy-in to this program?  What are some specific actions that may promote bundle usage by physicians? 1

Project Management Predicament  You are the Project Manager (PM) on a team charged with rolling out the ABCDE bundle to 7 inpatient facilities within a large health care system. You’ll be interacting with approximately 100 system personnel (across multiple disciplines) working across 13 ICUs as you execute each phase of the roll out. You’ve noticed that each unit is developing their own protocols, sometime duplicating efforts that have not worked well at other sites and creating performance variability between facilities.  As the PM, what are some strategies you would use to effectively streamline communication about this project (reports, spread of best practices, etc.)?  How do you coordinate this communication across a system (or even within a hospital) that is often disconnected and operates in siloes? 2

Same System, Miles Apart  Nearly a year into the ABCDE bundle implementation program (all sites have had access to a similar set of tool and training at this point), the project team notes significant variability between and within system hospital s (e.g., some sites are hitting the SBT component 95% of the time; other sites are stuck closer to the 55% range). It is also observed that there is no specific site that is “running on all cylinders” (i.e. excelling in one component of the bundle doesn’t predict high adoption rates for other bundle components).  How do you identify causative factors for this variability?  For processes demonstrated to be successful, how do you disseminate those tactics to other units and facilities?  You have been asked to explain this performance variability at an upcoming board meeting…what will the fix be, and how long will it take? 3

The Prodigal Nurse (2 parts)  During daily multidisciplinary rounds you ask a graduate nurse (who has just completed her ICU internship) if her patient received a SAT. She states she turned off the pain and sedation meds but the patient “never woke up” to progress to the SBT. You asked what time this happened and she states 2 hours ago. When you review the chart you note that the nurse restarted the sedative drips after they were off for 30“, despite the fact that the patient never woke up. The nurse did receive training during her internship on how to perform the SAT/SBT sequence, as well as education on indications for resumption of analgesia and sedation.  What is the teaching opportunity here?  What will your approach be in coaching this nurse (and other new grads on the unit)?  2 days later, during team rounds you observe the patient with his eyes wide open and he appears to be tracking you in the room. You ask the nurse about CAM—ICU results. The nurse states that the test was not able to be done because the patient has a head injury and the RASS was -3. You note the RASS is at -1 but has fluctuated during the past 24 hours. Patient is able to perform the SAVEAHAART with.  What are the teaching points regarding use of the CAM-ICU in this case?  What will your approach be to promote adoption and proper use of the CAM-ICU? 4

No Movement on Mobility  During daily multidisciplinary rounds the nurse states that the patient completed the SAT successfully but has not passed the SBT so will remain on the ventilator. Patient is alert and calm, eyes open, tracking, reading an education pamphlet and has not required sedation to be restarted. A plan is made to dangle the patient and if steady to transfer to the chair. When you return 4 hours later you find the patient in bed and on full sedation. You ask the nurse if the patient was mobilized. She states that PT wasn’t readily available able to come help, her other complex patient “went nuts on her” and her hall partner spent the last 2 hours in MRI, so she could not mobilize the patient. Eventually the patient became agitated so she had to restart the patient’s propofol drip.  What are the teaching points in this case?  How can mobility be hardwired into your unit given resource constraints and the unpredictable nature of critically ill patients? 5